Public Act 0282 95TH GENERAL ASSEMBLY

HB0192 Enrolled LRB095 03991 DRJ 24024 b

Public Act 095-0282

AN ACT concerning health.

Be it enacted by the People of the State of Illinois, represented in the General Assembly:

Section 5. The Mental Health and Developmental Disabilities Administrative Act is amended by adding Section 10.5 as follows:

(20 ILCS 1705/10.5 new)

Sec. 10.5. Prevention and control of Multidrug-Resistant Organisms. The Department, in consultation with the Department of Public Health, shall adopt rules that may require one or more of the facilities described in Section 4 of this Act to implement comprehensive interventions to prevent and control multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB), pursuant to updated prevention and control interventions recommended by the U.S. Centers for Disease Control and Prevention. The Department shall also require facilities to submit reports to the Department that contain substantially the same information contained in the related infection reports required to be submitted by hospitals to the Department of Public Health under Section 25 of the Hospital Report Card Act. The Department shall provide that information to the Department of Public Health upon the Department of Public Health's request.

Section 10. The Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois is amended by adding Section 2310-312 as follows:

(20 ILCS 2310/2310-312 new)

Sec. 2310-312. Multidrug-Resistant Organisms. The Department shall perform the following functions in relation to the prevention and control of Multidrug-Resistant Organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant (VRE) and certain gram-negative bacilli (GNB), as these terms are referenced by the United States Centers for Disease Control and Prevention:

(1) Except with regard to hospitals, for which administrative rules shall be adopted in accordance with Section 6.23 of the Hospital Licensing Act and Section 7 of the University of Illinois Hospital Act, the Department shall adopt administrative rules for health care facilities subject to licensure, certification, registration, or other regulation by the Department that may require one or more types of those facilities to (i) perform an annual infection control risk assessment, (ii) develop infection control policies for MDROs that are based on this assessment and incorporate, as appropriate, updated recommendations of the U.S. Centers for Disease Control and Prevention for the prevention and control of MDROs, and (iii) enforce hand hygiene requirements.

(2) The Department shall:

(A) publicize guidelines for reducing the incidence of MDROs to health care providers, health care facilities, public health departments, prisons, jails, and the general public; and

(B) provide periodic reports and updates to public officials, health professionals, and the general public statewide regarding new developments or procedures concerning prevention and management of infections due to MDROs.

(3) The Department shall publish a yearly report regarding MRSA and Clostridium difficile infections based on the Hospital Discharge Dataset. The Department is authorized to require hospitals, based on guidelines developed by the National Center for Health Statistics, after October 1, 2007, to submit data to the Department that is coded as "present on admission" and "occurred during the stay".

(4) Reporting to the Department under the Hospital Report Card Act shall include organisms, including but not limited to MRSA, that are responsible for central venous catheter-associated bloodstream infections and ventilator-associated pneumonia in designated hospital units.

(5) The Department shall implement surveillance for designated cases of community associated MRSA infections for a period of at least 3 years, beginning on or before January 1, 2008.

Section 15. The University of Illinois Hospital Act is amended by adding Section 7 as follows:

(110 ILCS 330/7 new)

Sec. 7. Prevention and control for Multidrug-Resistant Organisms. The University of Illinois Hospital shall develop and implement comprehensive interventions to prevent and control multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB), that take into consideration guidelines of the U.S. Centers for Disease Control and Prevention for the management of MDROs in healthcare settings. The Department of Public Health shall adopt administrative rules that require the University of Illinois Hospital to perform an annual facility-wide infection control risk assessment and enforce hand hygiene and contact precaution requirements.

Section 20. The Hospital Licensing Act is amended by adding Section 6.23 as follows:

(210 ILCS 85/6.23 new)

Sec. 6.23. Prevention and control of Multidrug-Resistant Organisms. Each hospital shall develop and implement comprehensive interventions to prevent and control multidrug-resistant organisms (MDROs), including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and certain gram-negative bacilli (GNB), that take into consideration guidelines of the U.S. Centers for Disease Control and Prevention for the management of MDROs in healthcare settings. The Department shall adopt administrative rules that require hospitals to perform an annual facility-wide infection control risk assessment and enforce hand hygiene and contact precaution requirements.

Section 25. The Hospital Report Card Act is amended by changing Section 25 as follows:

(210 ILCS 86/25)

Sec. 25. Hospital reports.

(a) Individual hospitals shall prepare a quarterly report including all of the following:

(1) Nursing hours per patient day, average daily census, and average daily hours worked for each clinical service area.

(2) Infection-related measures for the facility for the specific clinical procedures and devices determined by the Department by rule under 2 or more of the following categories:

(A) Surgical procedure outcome measures.

(B) Surgical procedure infection control process measures.

(C) Outcome or process measures related to ventilator-associated pneumonia.

(D) Central vascular catheter-related bloodstream infection rates in designated critical care units.

(3) Information required under paragraph (4) of Section 2310-312 of the Department of Public Health Powers and Duties Law of the Civil Administrative Code of Illinois.

The infection-related measures developed by the Department shall be based upon measures and methods developed by the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Joint Commission on Accreditation of Healthcare Organizations, or the National Quality Forum.

The Department shall include interpretive guidelines for infection-related indicators and, when available, shall include relevant benchmark information published by national organizations.

(b) Individual hospitals shall prepare annual reports including vacancy and turnover rates for licensed nurses per clinical service area.

(c) None of the information the Department discloses to the public may be made available in any form or fashion unless the information has been reviewed, adjusted, and validated according to the following process:

(1) The Department shall organize an advisory committee, including representatives from the Department, public and private hospitals, direct care nursing staff, physicians, academic researchers, consumers, health insurance companies, organized labor, and organizations representing hospitals and physicians. The advisory committee must be meaningfully involved in the development of all aspects of the Department's methodology for collecting, analyzing, and disclosing the information collected under this Act, including collection methods, formatting, and methods and means for release and dissemination.

(2) The entire methodology for collecting and analyzing the data shall be disclosed to all relevant organizations and to all hospitals that are the subject of any information to be made available to the public before any public disclosure of such information.

(3) Data collection and analytical methodologies shall be used that meet accepted standards of validity and reliability before any information is made available to the public.

(4) The limitations of the data sources and analytic methodologies used to develop comparative hospital information shall be clearly identified and acknowledged, including but not limited to the appropriate and inappropriate uses of the data.

(5) To the greatest extent possible, comparative hospital information initiatives shall use standard-based norms derived from widely accepted provider-developed practice guidelines.

(6) Comparative hospital information and other information that the Department has compiled regarding hospitals shall be shared with the hospitals under review prior to public dissemination of such information and these hospitals have 30 days to make corrections and to add helpful explanatory comments about the information before the publication.

(7) Comparisons among hospitals shall adjust for patient case mix and other relevant risk factors and control for provider peer groups, when appropriate.

(8) Effective safeguards to protect against the unauthorized use or disclosure of hospital information shall be developed and implemented.

(9) Effective safeguards to protect against the dissemination of inconsistent, incomplete, invalid, inaccurate, or subjective hospital data shall be developed and implemented.

(10) The quality and accuracy of hospital information reported under this Act and its data collection, analysis, and dissemination methodologies shall be evaluated regularly.

(11) Only the most basic identifying information from mandatory reports shall be used, and information identifying a patient, employee, or licensed professional shall not be released. None of the information the Department discloses to the public under this Act may be used to establish a standard of care in a private civil action.

(d) Quarterly reports shall be submitted, in a format set forth in rules adopted by the Department, to the Department by April 30, July 31, October 31, and January 31 each year for the previous quarter. Data in quarterly reports must cover a period ending not earlier than one month prior to submission of the report. Annual reports shall be submitted by December 31 in a format set forth in rules adopted by the Department to the Department. All reports shall be made available to the public on-site and through the Department.

(e) If the hospital is a division or subsidiary of another entity that owns or operates other hospitals or related organizations, the annual public disclosure report shall be for the specific division or subsidiary and not for the other entity.

(f) The Department shall disclose information under this Section in accordance with provisions for inspection and copying of public records required by the Freedom of Information Act provided that such information satisfies the provisions of subsection (c) of this Section.

(g) Notwithstanding any other provision of law, under no circumstances shall the Department disclose information obtained from a hospital that is confidential under Part 21 of Article 8 of the Code of Civil Procedure.

(h) No hospital report or Department disclosure may contain information identifying a patient, employee, or licensed professional.

(Source: P.A. 93-563, eff. 1-1-04; 94-275, eff. 7-19-05.)

Section 99. Effective date. This Act takes effect upon becoming law.

Effective Date: 8/20/2007